Transitioning services to telemedicine and federal assistance through the Paycheck Protection Program were pivotal for primary care practices in 2020.
Primary care physicians (PCPs) have endured daunting challenges during the coronavirus pandemic, but a combination of business savvy and external support has helped many of them to keep serving patients, a new report says.
Particularly in the early phase of the pandemic last spring, primary care practices experienced dramatic reductions in patient volume as patients avoided medical offices due to fear of coronavirus infection. Two Florida-based practices interviewed for the new report experienced deep reductions in patient volume during the early weeks of the pandemic, with one practice reporting a 60% decrease and the other practice reporting a 75% decrease.
The new report, which was published by the Urban Institute with funding from the Robert Wood Johnson Foundation, is based on a review of published data that documents PCP pandemic experiences and interviews with 16 PCPs. The size of the physician practices that were interviewed ranged from a solo practitioner to a practice that employs 370 physicians. The practices operated in 10 states: California, Florida, Georgia, Massachusetts, Michigan, Missouri, New Jersey, North Carolina, Texas, and Virginia.
PCPs have faced major challenges during the pandemic, the report says. "The PCPs we interviewed provide a window on how the COVID-19 pandemic has challenged our already-fragile system of primary care. These have included threats to their financial viability, particularly for smaller, independent PCP practices, and difficulties delivering quality care while ensuring safety for their patients, clinicians, and staff."
However, the PCPs interviewed for the report found ways to overcome their difficulties. "These PCPs have proven to be capable and nimble business owners, quickly shifting to new modes of care delivery. They have also taken advantage of government and community support to sustain their ability to serve their patients," the report says.
But perseverance has come with a considerable negative consequence. "These efforts have taken their toll, and many report a significant level of burnout that could have long-term implications for our nation's system of primary care," the report says.
Struggle for survival
Most PCPs reported severe financial pressure in the early phase of the pandemic.
In addition to the financial hit from reductions in patient volume, several PCPs discontinued offering "non-essential" services such as physicals to reduce potential coronavirus exposure for patients and staff. Discontinuation of these services was a drain on revenue. "Most PCP respondents reported dramatically reduced revenue in the early phases of the pandemic. For example, a Massachusetts doctor reported that his practice experienced a 40% decline in revenue," the report says.
PCPs also reported significant difficulty in securing adequate personal protective equipment (PPE) during the pandemic. "Most reported that acquiring necessary PPE has been difficult, if not impossible, at multiple points during the pandemic. This was particularly true for the smaller practices, which must compete with large health systems and hospitals for supplies," the report says.
Acquiring PPE contributed to higher costs during the pandemic, PCPs reported.
The financial woes required many PCPs to cut costs, the report says. "Several PCPs reported that they reduced their own salaries, imposed staff furloughs, pay cuts, or implemented a combination of these tactics."
Transition to telemedicine
Nearly every PCP interviewed for the report had shifted a significant level of services to telehealth, which not only increased safety during the pandemic but also boosted revenue. "A Missouri doctor told us that, without telehealth, they would be under 50% capacity. The practices also reported that purchasing the necessary technology and engaging with telehealth vendors was relatively affordable," the report says.
Reimbursement rules have been favorable for telehealth during the pandemic. During the public health emergency, Medicare is reimbursing telehealth visits at the same level as in-person visits. "Several PCPs practiced in states that require private insurers to do the same," the report says.
External support
Federal assistance and community support has helped PCPs stay in business, the report says.
The most consequential external support reported was the Paycheck Protection Program (PPP) established through the Coronavirus Aid, Relief, and Economic Security (CARES) Act. PPP funding was more helpful to primary care practices than the Provider Relief Fund (PRF), which allocated $175 billion to compensate providers for decreased revenue or treatment costs associated with the pandemic, the report says.
"Recipients of PPP loans who used the funds for payroll, business mortgage interest payments, rent, or utilities can request loan forgiveness, relieving them of any obligation to pay back the funds. Of the PRF funds, the federal government distributed a large portion automatically to providers who participate in Medicare, based on their total net patient revenue. This resulted in large hospitals and health systems receiving the bulk of the money; small PCP practices have received a relatively small proportion of these funds."
While not as significant as the PPP funding, communities also helped primary care practices, the report says. "Many practices reported that they had received donations from local residents, foundations, and non-profits. Some donated PPE and provided financial assistance. One doctor reported that patients were making them masks."
Primary care practice forecast
Reimbursement looms large for primary care practices in the second year of the pandemic, the lead author of the study told HealthLeaders.
"Many practices continue to rely on telemedicine for a significant portion of services, so continued adequate reimbursement will be important. Over the longer term, some practices may be more willing to enter into capitated arrangements with payers, in which they agree to treat patients for a pre-set amount each month, regardless of the number of services delivered," said Sabrina Corlette, JD, research professor, founder, and co-director of the Center on Health Insurance Reforms at Georgetown University's McCourt School of Public Policy.
After the coronavirus crisis has passed, Corlette predicted there will be three dominant trends at primary care practices. "I suspect the trend toward consolidation and acquisition will continue, more practices will be open to taking on capitated forms of payments, and the delivery of services via telemedicine will be here to stay."
At Cedars-Sinai, a volunteer team of experienced physicians is placing central and arterial lines in COVID-19 ICUs.
A volunteer "COVID Line Team" at a Los Angeles–based medical center has boosted the efficiency of placing central and arterial lines in COVID-19 ICUs and taken pressure off busy critical care teams.
During coronavirus patient surges, hospital ICUs often become inundated with severely ill patients. The COVID Line Team at Cedars-Sinai Medical Center has increased the efficiency of placing central and arterial lines in coronavirus patients and freed up precious time for the dedicated ICU clinical staffs.
The COVID Line Team was formed in March 2020 during the first coronavirus patient surge in Los Angeles, says the team's leader, Evan Zahn, MD, director of the Guerin Family Congenital Heart Program at Cedars-Sinai's Smidt Heart Institute.
"I sent out emails to departments where I thought the expertise was located. We had a remarkable response. We got several physicians from anesthesia, who are obviously good at placing lines. We got pediatric intensivists. We have a wonderful procedural center here, and those clinicians are super talented and have participated in a big way," he says.
With elective procedures on hold during the first coronavirus patient surge, Zahn was able to recruit nearly 20 physicians to work on the COVID Line Team, and they were able to place lines in COVID-19 ICUs around the clock. "We had anesthesiologists with tremendous skill not practicing. I was not scheduling elective cases with babies. We had the time to provide a 24/7 service, and we were heavily utilized," Zahn says.
The COVID Line Team has generated several advantages, he says.
With experts who are efficient at placing lines, there are quicker procedure times. "The bedside nurses tell us that when they have a line that is challenging, it can take an hour or hours for an ICU clinician to get the line in. For the COVID Line Team, it is very unusual for any line to take more than 10 or 15 minutes," Zahn says.
The speedy procedures free up time for ICU nurses. "They are standing there assisting us in placing lines for only a few minutes, so they can get back to taking care of patients," he says.
The COVID Line Team reduces the exposure of ICU clinicians to the coronavirus. "When we walk into an isolation room, we protect the junior house staff and junior physicians from coronavirus exposure. Similarly, the ICU medical team does not have to do the donning and doffing of personal protective equipment to perform the procedure. They can be figuring out a strategy to care for the patient rather than doing the mundane tasks of putting in these lines," Zahn says.
The COVID Line Team has been able to keep complications minimal. "We are a highly trained, highly experienced group that has been doing these procedures for many years. These are patients who are quite ill, and they cannot afford to have line complications. Our line complication rate has been almost nonexistent because we have such an experienced group of operators," he says.
Practice makes perfect
Utilizing the medical center's simulation center was one of the keys to success for the COVID Line Team, Zahn says.
"We did not just show up as a line team. Before we started placing lines in the ICU, we spent several days in our simulation center, which was set up to look exactly like an ICU. We worked out exactly where each piece of equipment would go and exactly how we would go into the isolation room. As with all technical things, the more planning you do, the more efficient you are," he says.
The simulation work has eased the process of adding new members to the COVID Line Team, Zahn says. "Once we had our simulation set, we created instructional videos and virtual reality for COVID lines that we could use to train our new members quickly. They could do the simulation work, watch a couple of procedures, and be ready to go."
The simulation center was also pivotal in training the COVID Line Team how to operate with cumbersome personal protective equipment, he says. "Walking around with the kind of PPE we wear to do these procedures is not a normal thing, and none of us were really experienced in that part of this work. The simulation center was invaluable. The line part was easy for us. But how you do this work and stay safe and keep the nurse safe and minimize your time in the room while maximizing your efficiency can all be achieved through simulation."
Logistics and supply chain
Robert Wong, MD, a pediatric cardiac anesthesiologist, has led the logistical effort to keep the COVID Line Team well organized, Zahn says.
"He puts out a monthly schedule for the COVID Line Team physicians. Through some of his technicians, he organizes all of the supplies, so we have all of the lines and the accessories you need to get them in. Robert has organized a supply chain, so that whenever we go to a COVID ICU, all of the supplies are readily available."
COVID Line Team metrics
The COVID Line Team has been tracking a limited set of metrics to assess quality of care and staffing issues, Zahn says. "We did not set out to do this as an academic exercise. It was much more a call to arms, and we followed very simple quality metrics that we felt were important to track."
Weekly quality meetings generated a data-driven gain early in the program, he says. "One of the things we noticed early on was that we were losing arterial lines due to thrombosis, and this was before it was widely known that these patients were hyper thrombotic. Through quality improvement, we were able to quickly heparinize lines to prevent them from clotting."
Zahn has been tracking operators, time spent in isolation rooms, and how many lines a clinician does. "I was basically asking people to stand in harm's way. I felt the responsibility of protecting the people who were risking exposure to the coronavirus, and it was important to me that nobody got over-exposed and subsequently ill. The proof is in the pudding—no one got hospital-acquired COVID on our team."
They also have been tracking utilization of central, venous, arterial, and dialysis catheters. "We noticed at a certain point that there was a marked increase in dialysis catheters, which signified that the degree of illness that we were seeing was increasing with renal failure, and we discussed this with the ICU team," he says.
Other metrics are related to staffing and physician performance, Zahn says. "We look at percentage of lines placed on weekdays versus weekends so we can meet our staffing needs. We look at the number of lines placed by junior physicians versus senior physicians to see if there is a difference in outcomes."
Many patients from socially vulnerable communities lack essential resources to achieve optimal surgical outcomes, researcher says.
Cancer surgery patients who live in socially vulnerable communities have a higher likelihood of adverse outcomes than other patients, a recent research article says.
Social determinants of health are widely recognized as a key component of healthcare inequities. "Social determinants of health such as poverty, unequal access to healthcare, lack of education, stigma, and racism are underlying, contributing factors of health inequities," the Centers for Disease Control and Prevention (CDC) says.
The recent research article, which was published by the Journal of the American College of Surgeons, is based on data collected from more than 200,000 cancer surgery patients.
The study evaluated the relationship between "textbook outcomes" and social vulnerability, which was measured using the CDC's Social Vulnerability Index (SVI). A textbook outcome was defined as the absence of complications, extended length of stay, readmission, and mortality. The SVI features 15 variables drawn from U.S. Census data, including poverty, vehicle access, and the quality of housing.
The study includes three key data points.
Patients with a high SVI ranking were more likely to experience complications than patients with a low SVI ranking: 24.0% of high-SVI patients experienced complications vs. 21.5% of low-SVI patients.
Patients with a high SVI ranking were more likely to experience 90-day mortality than patients with a low SVI ranking: 8.4% of high-SVI patients experienced 90-day mortality vs. 7.0% of low-SVI patients.
Race was also associated with adverse outcomes. White patients with a high SVI ranking had 10% lower odds of having textbook outcomes. Non-white patients with a high SVI ranking had 22% lower odds of having textbook outcomes.
"Collectively, the data strongly suggested that cancer patients from areas characterized by high social vulnerability were at higher risk of adverse postoperative outcomes independent of other measured variables," the study's co-authors wrote.
Interpreting and assessing the data
The corresponding author of the study told HealthLeaders the data features three findings.
"First, we found that patients who were black or Hispanic were disproportionately represented in high socially vulnerable communities. Second, even if you did not look at race and ethnicity, if you resided in a community that was very vulnerable, then you had a very much higher risk of having worse outcomes postoperatively. Third, if you happened to be a minority and living in a socially vulnerable neighborhood, it had an additive effect. So, those patients were in double jeopardy for having lower odds for an optimal outcome after surgery," said Timothy Pawlik, MD, PhD, MPH, surgeon-in-chief at The Ohio State University Wexner Medical Center, and chair at the Department of Surgery, The Ohio State University College of Medicine, Columbus, Ohio.
Patients with a high SVI ranking lack critical resources to lower the odds of adverse surgical outcomes, he said.
"The SVI is basically reflective of how rich the resources are in a community. If you have bad transportation, it is hard for you to get to your clinic appointment or to get to the hospital in a timely manner. If you have substandard housing, it is going to make it much more challenging after you get discharged from a complex operation to have as good a recovery compared to a patient who is discharged home to a much more affluent setting that has many more resources. For socioeconomic status, if you are discharged home into a community that is more economically deprived, it is more difficult to get the resources that you need such as food, transportation, and assistance to recover from your surgery."
Impact of race on outcomes
The study's data reflect systemic racial inequalities in the country, Pawlik said.
"We know that patients who are black or Hispanic have worse healthcare outcomes than their white counterparts, even after you control for insurance status and disease stage. The data that we present in this paper shows that even if you control for social vulnerability, black and Hispanic patients still did worse. If black and Hispanic patients are also in a socially deprived or vulnerable neighborhood, it is even more difficult for them to overcome barriers."
Addressing social vulnerability
Physicians and hospitals can take actions to address social vulnerability at the patient level, Pawlik said.
"There are good screening tools that are available to do this work. If we can identify that a patient comes from a socially vulnerable community or environment, then we can mobilize resources in the hospital such as social work, patient care managers, and patient navigators to interact with patients to get them the resources that they may need around housing, food insecurity, and transportation."
At the community level, healthcare organizations need to support efforts to build healthy neighborhoods, he said. "We need to look beyond the doors of our hospital and begin to look at systematic change in the environments in which our patients live. We need to create healthy communities because that will ultimately help us achieve better outcomes in perioperative care."
AMGA president and CEO calls on Congress to act on several of the organization's priorities, including coronavirus vaccination and promotion of telemedicine.
In a letter this week to U.S. House of Representatives Speaker Nancy Pelosi, the leader of the AMGA presents the organization's eight priorities for 2021.
The AMGA, formerly known as the American Medical Group Association, represents more than 440 multispecialty medical groups, hospitals, and health systems nationwide. About 175,000 physicians work at AMGA member organizations.
AMGA members have been pivotal players in the country's response to the coronavirus pandemic, wrote AMGA President and CEO Jerry Penso, MD, MBA. "Our medical groups and integrated systems have been on the frontlines of this public health emergency from the beginning and have navigated the new normal to continue providing high-quality, cost-effective, and patient-centered medical care."
In his letter to Pelosi, Penso highlighted eight AMGA priorities for 2021:
1. COVID-19 vaccination
Multispecialty medical group practices are on the frontline of the pandemic and should be involved in coronavirus vaccination efforts, Penso wrote. Practices bring several strengths to the task, he wrote.
Practices have existing relationships with patients, which can facilitate vaccinations
Practices have structures and processes in place to administer vaccines
With the two vaccines approved so far requiring two doses, practices are well-suited to use existing relationships with patients to schedule, manage, and document the process of administering two shots
AMGA members should play an important role in distributing coronavirus vaccines, Penso wrote.
"Our members have the storage and staffing requirements necessary for the vaccine, but to ensure operational success, medical groups should be notified three to four weeks in advance of the number of doses they will receive. With a dedicated supply of vaccine and support, including the necessary financial support for staff, tents, and the other logistical needs to manage vaccine operations, medical groups are well positioned to quickly help vaccinate as many patients as possible."
2. Funding healthcare provider relief during the pandemic
Penso acknowledged the financial support Congress has already provided to healthcare providers through the Public Health and Social Services Emergency Fund (Provider Relief Fund) and called for more funding.
"AMGA recommends at least an additional $100 billion in new appropriations to the Provider Relief Fund during this upcoming legislative session. The increase in the number of cases, the need to cancel elective procedures, influenza season, and the current winter months create a confluence of conditions that will strain healthcare systems' ability to respond to this national crisis," he wrote.
In addition, Penso called for legislation that would make Provider Relief Fund money tax-free for for-profit healthcare provider organizations. "All providers, regardless of tax status, should receive the maximum amount of support from the Provider Relief Fund since it is intended to ensure the viability of our healthcare system."
3. Bolstering telehealth
Telemedicine growth has been one of the positive developments of the pandemic, and Congress should promote telehealth, Penso wrote. "Not only does telehealth increase access to care, it also leads to improved spending efficiency in the healthcare system."
Congress and the Centers for Medicare and Medicaid Services should take several actions to bolster telemedicine during and after the pandemic, he wrote.
Payment parity between telehealth visits (including audio-only services) and in-person visits should be ensured
Congress should approve the Temporary Reciprocity to Ensure Access to Treatment (TREAT) Act, which provides state reciprocity in healthcare professional licensing to allow them to practice across state lines during the pandemic
4. Care for chronic illness
Penso called for reforming the chronic care management (CCM) code in the Medicare Physician Fee Schedule, which reimburses clinicians for non-face-to-face care management.
"Medicare beneficiaries are subject to a 20% coinsurance requirement to receive the service. Consequently, only 684,000 patients out of 35 million eligible Medicare beneficiaries with two or more chronic conditions benefitted from CCM services over the first two years of the payment policy. Removing the coinsurance payment would facilitate more comprehensive management of chronic care conditions and improve the health of Medicare patients," he wrote.
5. Medicare sequestration cuts
Penso called on Congress to continue to spare healthcare providers Medicare sequester cuts. "Congress temporarily halted the Medicare sequester cuts through March 31, 2021. Given that COVID-19 relief and recovery efforts will go on throughout this year, Congress should approve the Medicare Sequestration COVID Moratorium Act, which would continue to halt Medicare sequester cuts until the end of the public health emergency," he wrote.
6. Closing coverage gaps in the Affordable Care Act
The Affordable Care Act should be improved to provide affordable healthcare coverage to more Americans, Penso wrote. "The COVID-19 pandemic exposed certain gaps in health insurance coverage that must be addressed in order to ensure that Americans have increased affordability and coverage. Congress must take additional actions to strengthen the Affordable Care Act by expanding subsidies, extending enrollment periods, and creating caps on premium contributions."
7. Increasing provider access to data
Congress should pass legislation that would give healthcare providers access to commercial payers' administrative claims data, Penso wrote.
"Having access to claims data plays a critical role in patient care coordination. … Not only does access to commercial claims data help providers deliver better care, but it additionally empowers the patient. Patient access to health data will only lead to better conversations with their providers and subsequently to better health outcomes. Access to data also ensures more accountability between the provider and the payer regarding a patient's care."
8. Advancing health equity
To promote health equity, Congress should act to reduce barriers to accessing medical care and social services, Penso wrote.
"It is important that Congress create legislative frameworks that address the underlying causes of inequality in the healthcare system. To that end, we support the passage of the Social Determinants Accelerator Act introduced last Congress. The legislation provides grants to assist communities with evidence-based approaches to coordinate health and social services, a key element to increasing health equity in underserved communities."
The Teletherapist Network is member-driven and emphasizes quality over quantity.
A private online network for therapists is designed to provide professional and social support as the field transitions to teletherapy during the coronavirus pandemic and beyond.
Mental health conditions have been among the top diagnoses treated through telemedicine since the beginning of the pandemic in March 2020. In August 2020, mental health conditions accounted for 48.93% of all telehealth diagnoses, according to claims data tracked by FAIR Health.
The Teletherapist Network was launched in July 2020 with 100 members and currently has about 120 members. Once the roster hits 200 members, a wait list will be implemented. The membership fee for the network is $24.99 every two weeks.
The goal of the Teletherapist Network is to create a vibrant, socially engaged, and knowledgeable community of therapists, the network's founder told HealthLeaders.
"I created the network as a way for clinicians to join and develop relationships with each other. I wanted us to get to know each other's clinical strengths and weaknesses, then take advantage of the community aspect and collective knowledge of a private group that interacts on a personal and professional level," says Kathryn Esquer, PsyD, MBA, MA, a clinical psychologist at Family Practice Center, PC, in Selinsgrove, Pennsylvania.
The pandemic spurred creation of the network, she says.
"In March 2020, we had to switch to telehealth, which became a primary way to get healthcare, including mental healthcare. I struggled to find a quality group of peers from whom I could get information and best practices from. I found a lot of Facebook groups that were semi-private. There was a lot of information there but not quality connections or a high degree of trust in the information that was being shared. I wanted to make sure that we had quality connections, not just another large forum with impersonal posts," Esquer says.
The Teletherapist Network is well-suited to help therapists deal with the upheavals associated with the pandemic and other events over the past year, she says. "We as mental health providers have helped our clients through a pandemic shutdown with isolation, through political unrest, and through a social justice movement while experiencing these events ourselves. It's a very tricky situation, and it is something we have never seen before in our field. We are going through events with our clients on a large-scale level."
The network's tightly knit community enables peers to guide each other through the professional challenges of tumultuous times, Esquer says. "In therapy, it is important to recognize what we as therapists bring into a therapy session. The only way to do that is to look inward and to seek consultation with our peers—to seek trusted licensed clinicians who can help us see where we might be biased or where we may be missing things with our clients. The more personal perspectives we bring into a therapy session, the more pitfalls we could have."
Teletherapist Network offerings
The network allows members to connect professionally and personally in a range of ways, Esquer says. "Over the past year, there has been a need for community among therapists, with social support, mental health support, and clinical support. None of us have experienced a mass transition to telehealth all at once. So, the group power and support on the network has been tremendous."
Daily discussions: In a post forum, members have daily discussions about personal challenges and developments in the field of mental health. "We talk about what we are struggling with in the moment in our own mental health. We offer personal and professional support. The daily discussions on professional topics can range from favorite HIPAA-compliant email platforms to addressing political topics during a therapy session when the client's views do not match your own views," she says.
Social hours: Twice per week, members gather virtually to connect on a personal level or to discuss professional issues.
Crowdsourcing: In an example of the network's emphasis on quality over quantity, members routinely share their exposure to new research articles and clinical information such as best practices generated at professional societies. "Instead of having one person having to stay up to date on the best practices coming out from all of the different research areas, we are crowdsourcing and sharing information with each other," Esquer says.
Live events: Twice a month, members gather virtually for two kinds of member-driven live events. A live consultation event features an unstructured discussion, where members can talk about client cases in a private and confidential manner. The other member-driven live event is a "rumble," where members discuss and debate a controversial issue in mental healthcare.
Outside speakers: At least once a month, the network hosts a virtual event featuring experts from inside the therapy field as well as experts associated with operational aspects of therapy practices. So far speakers have included clinical directors discussing therapy best practices, accountants addressing therapy practice tax considerations, and lawyers presenting information on contracts.
Teletherapy best practices
Besides discussing the Teletherapist Network, Esquer tells HealthLeaders about four best practices to determine whether a client is a good candidate for teletherapy. They follow below:
1. Client preference: A client should be asked whether he or she wants teletherapy as opposed to in-person sessions, and teletherapy should never be forced on a client. If you only offer teletherapy, you should have referrals ready for clients.
2. Technology considerations: Therapists should find out whether a client has the infrastructure to conduct teletherapy sessions such as a reliable Internet connection and access to a computer or smartphone. The client's ability to use electronic devices and to navigate the online platform should also be assessed.
3. Telecommuting location: The client should have a private and confidential space to conduct a teletherapy session. Ideally, the client should have a room where the door can be closed, so they can feel confident that what they say is private and confidential.
4. Clinical presentation: Teletherapy is not appropriate for some mental health conditions. "Teletherapy can help treatment progress, or teletherapy can be a barrier to treatment progress. For example, clients with agoraphobia who are afraid to leave their home may be contraindicated for teletherapy—you might be enabling them to not leave the home," Esquer says.
Health systems can use data from the new study to target medical conditions and specialties that had the highest rates of deferred care.
Telemedicine utilization by condition and medical specialty during the early phase of the coronavirus pandemic sheds light on deferred care, a new research article shows.
At the beginning of the pandemic, use of telemedicine surged as many clinicians turned to the technology to continue to see patients in a safe manner. Despite the uptick in telemedicine use, overall medical visits dropped substantially, which raises concern about deferred care, the new research article says.
The study, which was published today by Health Affairs, is based on data collected from 16.7 million Medicare Advantage and commercial insurance beneficiaries.
The researchers examined data for in-person and telemedicine outpatient care from Jan. 1, 2020, to June 16, 2020. Jan. 1 to March 17 was designated as the "pre-COVID-19 period" and March 18 to June 16 was designated as the "COVID-19 period."
The study generated several key data points:
30.1% of total outpatient visits were provided through telemedicine during the COVID-19 period, which amounted to a 23-fold increase in telemedicine use over the pre-COVID-19 period
Despite the increase in telemedicine visits during the COVID-19 period, overall outpatient visit volume fell 35.0%
During the COVID-19 period, at least half of clinicians in six specialties used telemedicine at least once: endocrinologists (67.7%), gastroenterologists (57.0%), neurologists (56.3%), pain management physicians (50.6%), psychiatrists (50.2%), and cardiologists (50.0%)
During the COVID-19 period, specialties that generally require in-person visits provided at least one telemedicine visit at a relatively low level, including orthopedic surgeons (20.7%), ophthalmologists (9.3%), physical therapists (6.6%), and optometrists (3.3%)
Specialties that conducted a larger percentage of total visits via telemedicine in the COVID-19 period had a smaller decrease in total visits per week from the pre-COVID-19 period to the COVID-19 period. During the COVID-19 period, five specialties conducted about half of total visits through telemedicine: psychiatry (56.8%), gastroenterology (54.5%), endocrinology (53.1%), social work (50.8%), psychology (49.1%), and neurology (47.9%).
On average, conditions for which a larger percentage of total visits were conducted through telemedicine in the COVID-19 period had a smaller decrease in total visits per week from the pre-COVID-19 period to the COVID-19 period. Conditions with the highest percentage of total visits provided through telemedicine in the COVID-19 period included mental illnesses such as bipolar disorder (55.0%), anxiety (53.9%), and depression (52.6%). For these conditions, total visits per week fell 11% or less from the pre-COVID-19 period to the COVID-19 period.
Some common chronic conditions had relatively low use of telemedicine and significant drops in total visit volume. For hypertension, 38.1% of visits were conducted through telemedicine and total visits fell 23.0%. For diabetes without complication, 33.9% of visits were conducted through telemedicine and total visits fell 30.6%.
There was low use of telemedicine visits for eye conditions, which was associated with large drops in total visits. For cataracts, 1.2% of visits were conducted through telemedicine and total visits fell 61.2%. For glaucoma, 2.6% of visits were conducted through telemedicine and total visits fell 52.2%.
Healthcare providers could use the research article's findings to target areas with the highest rates of deferred care, the study's co-authors wrote.
"Health systems could allocate resources to patient outreach efforts such as telephone calls or reminder messages, prioritizing patients whose conditions saw the largest drop in visit volume. Furthermore, additional clinical capacity could be allocated to specialties with the largest backlogs of deferred care. Finally, health systems could prioritize chronic illness populations, who were more likely to have deferred care, for targeted population management," they wrote.
Interpreting the data
The data indicates that several specialties stand out for deferred care during the coronavirus pandemic, study co-author Michael Barnett, MD, MS, told HealthLeaders.
"Ophthalmology definitely seems to be the hardest hit. There are plenty of chronic eye conditions that require regular checkups, including glaucoma and many retinal diseases. Other specialties with the largest backlog of deferred care include otolaryngology and dermatology," said Barnett, an assistant professor in the Department of Health Policy and Management at Harvard T.H. Chan School of Public Health in Boston.
During the early phase of the pandemic, specialties with the least telemedicine engagement such as optometrists, physical therapists, and ophthalmologists appear to have been ill-suited for the switch to telehealth, he said. "Our hypothesis is that these specialties rely heavily on in-person contact and may also have had the least infrastructure and cultural preparedness to transition to telemedicine among all specialties."
The relatively low use of telemedicine for common chronic conditions such as hypertension and diabetes without complication along with a significant decline in total visit volume for these conditions raises alarm, Barnett said.
"It is concerning, especially because we worry that the most disadvantaged populations are probably the ones with the most deferred care and highest need to maintain continuity of care. We do not have data yet to know about the magnitude of deferred care that may have led to worsening chronic illness control, but we think it is a very important public health concern to monitor."
The MGMA's leader says physician practices should be on the frontline of COVID-19 vaccination.
Many of the country's physician practices have been left out of the coronavirus vaccination effort, a new survey indicates.
Although the development of coronavirus vaccines has proceeded more rapidly than most public health experts predicted at the beginning of the pandemic last spring, vaccination efforts have been relatively slow in many states. For example, California is recasting the administration of vaccine after an inefficient rollout.
The new survey, which was released this week by the Medical Group Management Association (MGMA), is based on data collected from Jan. 21 to Jan. 24. The data was collected from 400 medical practices that are already vaccinating patients or are planning to vaccinate patients.
The survey features four data points:
71% of physician practices reported they were unable to obtain coronavirus vaccines for patients
85% of independent physician practices reported they were unable to obtain coronavirus vaccines for patients
45% of hospital or health system-owned physician practices reported they were unable to obtain coronavirus vaccines for patients
The majority of physician practices that have been able to get coronavirus vaccines report limited supply and only being able to vaccinate 1% or less of their patients
Prescription for physician practice involvement in COVID-19 vaccination
Physician practices should be the primary place for coronavirus vaccinations after the first phase of vaccination for frontline healthcare workers and people over 75, says Halee Fischer-Wright, MD, president and CEO of the MGMA, which is based in Englewood, Colorado.
"Physician practices are uniquely suited for the role. They have patient registers, they have methodology to keep track of vaccines, and they already have vaccine systems set up for their patients as evidenced by administration of flu vaccine, shingles vaccine, and other vaccines. This is not a new process for physician practices. It is already well established," she says.
Patients expect physician practices to play a major role in the vaccination effort, Fischer-Wright says.
"Cutting physician practices out of the entire supply chain has created issues in the sense that patients are already calling and utilizing practice resources to ask about where to get vaccine, how to get vaccine, when to get vaccine, and whether to get vaccinated. Practices are already answering those questions. It would be much more effective to take that time and resources and convert it to getting patients into practices to get vaccinated."
Physician practices involved in coronavirus vaccination should not be limited to primary care practices, she says.
"Any practice that handles chronic disease should also be involved. For example, nephrology practices would be a great place to get your vaccine if you are on dialysis or have end-stage renal disease. If you have congestive heart failure, your cardiology practice would be a great place to get your vaccine. If you have cancer, your oncology practice would be a great place to get your vaccine. Some of the most vulnerable people who are in most need of the vaccine are in medical specialty care."
Physician practices well-suited to address vaccination hesitancy
Physician practices are trusted sources of information, and they can have a positive impact on addressing vaccination hesitancy, Fischer-Wright says.
"We still have a significant population of people who do not want to get the vaccine because they do not trust it. For example, studies have shown that more than 40% of nursing home workers are turning down the vaccine because they do not trust the people who employ them and they do not trust the vaccine. You can address that by having nursing home workers get the vaccine from their personal physicians, where there is an establishment of trust."
Many patients are not getting cancer screening during the pandemic because of concern over potential infection at healthcare settings.
Decreased rates of cancer screening during the coronavirus pandemic could lead to a significant increase in cancer mortality, a cancer expert says.
People have been deferring care during the pandemic due to fear of contracting the coronavirus in healthcare settings. For five kinds of cancer, reduced cancer screening linked to the coronavirus pandemic has likely led to thousands of delayed cancer diagnoses, according to an IQVIA Institute report. For the three-month period ending June 5, 2020, the IQVIA Institute estimates there could have been more than 80,000 delayed positive diagnoses for breast, cervical, colorectal, lung, and prostate cancer.
Delays in cancer diagnoses lead to increases in cancer mortality, says Justin Klamerus, MD, president of Karmanos Cancer Hospital and Network, a division of the Karmanos Cancer Institute in Detroit. Karmanos facilities are owned by McLaren Health Care—a health system based in Grand Blanc, Michigan.
"The earlier stage that a cancer is diagnosed, the greater the likelihood that it can be cured. If you look at breast cancer, before the pandemic 92% of women who were diagnosed with breast cancer could be expected to be cured. That number is directly correlated to the stage of diagnosis. If you have a Stage 3 breast cancer with a large mass that has grown over time, there is a lower chance of survival. With a large mass, there is a higher chance of spread to lymph nodes and a higher chance of distance spread to other organs. When breast cancer spreads to other organs, it becomes incurable," Klamerus says.
Prevention is the No. 1 goal in cancer care, but screening is crucial, he says. "When we cannot prevent a cancer, identifying and diagnosing at the earliest stage in almost every cancer leads to a higher likelihood of a cure."
In the Karmanos network, screenings for all cancers were down 17.2% in the fiscal year ending October 2020 compared to the 2019 fiscal year. Mammograms were down 16.8% and colonoscopies were down 20.4%. Roughly 107,000 patients were screened for these cancers at Karmanos in 2019, versus 89,000 in 2020.
The early signs of the impact of decreased screening are troubling, Klamerus says. "Anecdotally, what we are seeing is that patients are presenting with more advanced stages of disease. They are avoiding symptoms that would normally lead to having tests done or seeing a doctor. Patients are avoiding that care because of the concerns over COVID-19."
Klamerus fears that the decrease in cancer screening linked to the coronavirus pandemic will lead to a significant increase in cancer mortality.
"For many decades, we saw that the death rates from cancer were increasing every year. In 2016, we saw cancer death rates fall for the first time and every year thereafter it had fallen. Many of us in cancer medicine are concerned that because of the pandemic, 2020 will be a year when we see that positive trend reverse and we will see an increase in cancer death rates because of individuals avoiding screening and seeing their physicians," he says.
The decrease in cancer screenings is part of a distressing national trend of deferred healthcare services during the pandemic, Klamerus says. "Deferred care is a second pandemic, which is not uncommon when you look at the history of pandemics."
Encouraging cancer screening
Karmanos has used an "all-hands-on-deck approach" to encourage patients to undergo cancer screening, Klamerus says.
"First, we recognized that our physicians and providers who have relationships with patients needed to directly reach out to those patients. We have provided instructional materials that could be used with patients to encourage screening and to make sure patients knew that we were doing everything possible as an organization to be a safe place for care," he says.
Karmanos has used multiple outreach channels to encourage screening, Klamerus says. "We did media campaigns through social media. We partnered with our McLaren Medical Group, which are our primary care physicians, to reinforce the importance of cancer screening."
Karmanos also mobilized cancer navigators, who work in the organization's cancer centers, he says. "We had those navigators work with our screening centers to try to identify patients who had missed screening and have direct contact with them. The navigators answered questions about concerns that patients had about accessing care and emphasized the safety of the care that was being provided at our facilities."
Infection control efforts
Karmanos and McLaren have taken several steps to prevent coronavirus infections in care settings, Klamerus says. "First of all, we have worked to make sure that our buildings are safe."
"You cannot get into our buildings unless you are screened for COVID-19 symptoms including a temperature check. We have limited visitors. We have aggressive cleaning of the patient rooms in clinic and ambulatory settings as well as our hospitals. We have ended practices such as semi-private rooms in inpatient settings—those are all private rooms now," he says.
Karmanos and McLaren have also embraced technology to reduce possible coronavirus exposure. In addition to increasing the use of telemedicine visits, they have reduced traffic in their waiting rooms, Klamerus says. "We have adopted new queuing systems for waiting rooms. We keep people in the parking lot longer, contact them on their cell phones, and bring them into our buildings just before their appointments to limit crowding."
Now, there is an emphasis on vaccination, he says. "We have had robust employee vaccination programs. As of January 6, we had 65% of our employees vaccinated, and we had two more waves of employee vaccinations in the two weeks after January 6. We are aiming to get as many people vaccinated as possible as we pivot from vaccinating frontline workers to getting patients and members of our community vaccinated."
Healthcare workers who experience long-term symptoms after their acute COVID-19 illness can struggle to do their jobs.
Employers should put measures in place to support healthcare workers who suffer from long-term symptoms after experiencing acute COVID-19 illness, a recent journal article says.
Gary Rogg, MD, an attending physician in internal medicine and co-director of the Post-COVID-19 Recovery Program at Westchester Medical Center in Valhalla, New York, says coronavirus "long haulers" can have a range of long-term symptoms. Those symptoms include cough, shortness of breath, anxiety and depression, cardiac issues, constitutional symptoms such as numbness and tingling, deconditioning, and hair loss.
The recent journal article, which was published by The Lancet Respiratory Medicine, says healthcare worker coronavirus long haulers can experience symptoms that interfere with the ability to do their jobs. "The barriers to returning to work are often low energy, cognitive symptoms, and affective symptoms. For example, a middle-aged, critical care nurse with years of both clinical and academic experience described having poor focus during patient encounters, forgetting names of essential medications, and debilitating fatigue after a typical workday," the co-authors wrote.
Recommendations to help healthcare worker coronavirus long haulers
A multidisciplinary team should be created to develop return-to-work strategies for healthcare worker coronavirus long haulers, the co-authors wrote. "This team might include individuals with specialism in neurology, psychiatry, psychology, pulmonology, physiatry, and other subspecialties, in collaboration with primary care staff."
Employers can take several actions to support coronavirus long haulers in their workforces, the co-authors wrote. "Examples include reintroduction into the workforce in phases, limiting shift schedules that disrupt natural circadian rhythms, mandating breaks to avoid post-exertional neurological symptoms, partnering with other workers to facilitate oversight while multitasking, and gradually increasing responsibility and workloads. Although these measures might be costly in the short term, they might also allow for a previously healthy, skilled healthcare professional to continue working long term."
Shift changes and easing workloads are effective strategies to get healthcare worker coronavirus long haulers back to work, the lead author of the journal article told HealthLeaders.
"In our experience, it does seem that reduced work hours and a flexible schedule avoiding night shifts to promote rest and recovery works best to prevent debilitating post-exertional fatigue. The creation of a backup or supervision system for employees returning to work might also be useful to avoid coverage gaps in the event of post-exertional fatigue while work hours are being gradually increased. Most importantly, we recommend dialogue between employers, employees, and occupational health about what is helpful on an individual basis," said Nathan Praschan, MD, MPH, a senior resident at Massachusetts General Hospital/McLean Hospital Adult Psychiatry Residency.
Employers should support healthcare worker coronavirus long haulers to help ensure adequate staffing during the pandemic, he said. "We think supporting healthcare workers struggling with long-term sequelae of COVID-19 as they return to work will help maintain the workforce as it continues to handle the pandemic. Not only that but also failing to do so would amount to moral injury among healthcare workers and contribute to burnout."
A new survey finds that concern over side effects is the top reason for coronavirus vaccination hesitancy.
A new survey highlights people's attitudes about coronavirus vaccination and suggests good strategies for healthcare providers to communicate with patients about getting coronavirus vaccines.
Vaccination hesitancy among the American public is one of the primary challenges facing the coronavirus vaccination effort across the country. Vaccination is widely viewed as essential to controlling the coronavirus through herd immunity, which occurs when a large proportion of a population develops resistance to an infection.
The new survey was conducted in December by Denver-based Welltok and Ipsos, a Paris, France-based market research company. The online survey features information collected from 1,000 U.S. adults nationwide.
The survey includes several key findings:
The Top 3 desired sources of information on coronavirus vaccines were healthcare providers (86% of survey respondents), health insurance company (81%), and pharmacy (79%)
69% of survey respondents said they would get the vaccine when it became available to them
64% of survey respondents said they wanted reminders for second doses of the vaccine
Among survey respondents who said they would not get the vaccine, 64% cited side effects as the cause of their vaccination hesitancy
82% of people who were immunized for influenza this year intend to get the COVID-19 vaccines
51% of people who did not get the flu shot this year intend to get the COVID-19 vaccine
Age was strongly correlated with intent to get vaccinated: 82% of people 55 and over planned to get vaccinated, 65% of people 35 to 54 planned to get vaccinated, and 58% of people 18 to 34 planned to get vaccinated
"The COVID-19 vaccines offer a ray of hope for many, but just because vaccines are available doesn't mean everyone will get the shot. Getting people vaccinated against COVID-19 will require personalized and consistent outreach," the survey report says.
Healthcare provider messaging about coronavirus vaccination
Clinicians and other healthcare providers are well-positioned to be a trusted source of information about the coronavirus vaccines, Welltok Chief Strategy Officer April Gill told HealthLeaders.
"Healthcare providers see their patients year over year. Healthcare providers track your progress as a human being from a medical standpoint, and they help patients determine when something is wrong. So, they have to be a trusted source of information about patient health," she said.
Healthcare providers can ease people's concerns about coronavirus vaccination side effects, Gill said.
"You need to be able to assure people that vaccinations are not new and explain that vaccines go through a vigorous process of clinical trials and testing before they are released to the public. In addition, patients can be told that the side effects associated with the COVID-19 vaccines are similar to the side effects for other vaccines—they are relatively mild. The side effects include some redness or swelling at the injection site, fatigue, and muscle aches that typically resolve themselves within a few days."
To encourage younger people to get coronavirus vaccination, healthcare providers can appeal to their relationships with family members, she said. "Young people need to know that when they interact with older people in their family, they are putting those people at risk if they do not get the vaccine. This is part of focusing on values and focusing on what people want to do in their lives. Focusing on what is important to young people such as spending time with older family members is critical."
For healthcare providers, the top methods of communication preferred by survey respondents were personal email, phone calls, text messages, postcards, work email, and social media posts.
"Based on the survey data, there is plenty of information indicating that messaging should be conducted in multiple channels so that you can reach as many people as possible. Healthcare providers should be using every channel at their disposal to get vaccination messaging out," Gill said.
Healthcare providers should also vary their messaging to appeal to specific populations, she said. "For example, older patients are going to have different motivations and things that they are considering than younger patients such as being able to spend time with grandchildren and enjoy their retirement. For younger patients who may feel invincible, clinicians can tell them how vaccination is important to protect the people they care about."
